Medicare Enrollment Revocation Occurring for Providers Reasons May Catch Most By Surprise

When it comes to Medicare, no provider wants to hear revocation.  The term revocation has a direct impact on reimbursement and hence the bottom line.  In a world where federal funds are always in jeopardy, the idea of having stumbling blocks in reimbursement always gets our attention.

MPR has learned that revocations of Medicare enrollments are occurring for physicians and other providers not only in jurisdictions where providers have previously practiced; but revocations are now occurring for the Medicare enrollments where they currently practice.   Revocation is a serious problem resulting not only in termination of a main artery of  the revenue stream, but also the debarment of re-enrollment in the Medicare program for no less than one year.

With all the changes in Medicare reimbursement it’s hard to believe this would come as a surprise.  But any change in reimbursement deserves attention.

Here is an example.  The good news is that MPR can help you become proactive in Medicare reimbursement.

Dr. Jones was in the midst of his fellowship and as required had a valid state license.   During his fellowship training, he was enrolled in Medicare Part B in the state jurisdiction to receive Medicare reimbursement for valid services.  The problems began when Dr. Jones completed his fellowship.  He left the state where he received his training and moved to another state to begin practice.  When the time came to renew his license in the state where his training was received Dr. Jones chose not to pursue the renewal.  Why would he?  He didn’t practice in the state any longer.

When he left his training program, his enrollment with Medicare was not reassigned so Dr. Jones’ enrollment remained active in that state.

Decision point number one; Dr. Jones could have initiated a voluntary termination of his Medicare enrollment, but why would he terminate enrollment in a federal health plan?  He was obviously not aware of the Medicare enrollment rules and the implications of the failure to terminate the enrollment.

What we know is that Medicare licensing boards in the states share information with Medical contractors.  Following the expiration of Dr. Jones medical license in the state where he was trained, that state’s Medicare contractor received information from the board indicating Dr. Jones’ medical license had expired.  The Medicare contractors revoked Dr. Jones’ Medicare enrollment and Dr. Dr. Jones never received communication notifying him of the revocation.  After all how would they reach Dr. Jones?  They didn’t know how to contact him.

Now we have an enrollment revocation and big problems on the horizon for Dr. Jones.  If a provider has an enrollment revoked, they then have an obligation to report this “adverse legal” action to their current Medicare contractor.  Dr. Jones was now working in another state and enrolled in Medicare under the new practice in that state.  Not being aware of the revocation, he made no disclosure to the state Medicare program where he was currently practicing regarding the revocation of his enrollment in the state where he was trained.

What do we know?  Well, we know Medicare contractors are able to share information through the PECOS enrollment system.  The Medicare program in the state where Dr. Jones was trained became aware of Dr. Jones revocation due to an expired medical license in this state where he was trained.

Recently Dr. Jones received a letter from the state Medicare program where he was trained indicating his enrollment would be revoked since he not disclose the revocation!

This action resulted in Dr. Jones having to complete a Corrective Action Plan (CAP) to prevent the revocation and is currently in progress.  Wow, what a hassle for Dr. Jones.  He now has to regularly follow up on the CAP application to insure it is in process and continue the appeals process should it become necessary.

Time spent with Medicare that Dr. Jones could be spending in the delivery of patient care.

What Should You Do to Be Proactive and How Can MPR Help?

1)      Check the PECOS enrollment records for your providers to insure there are no revocations listed in PECOS for other Medicare jurisdictions where the provider has worked or trained.   MPR can do that for you.

2)      If you note a revocation, immediately disclose it to the provider’s current Medicare contractor by completing either a paper enrollment (855I) or a PECOS enrollment.  MPR can do that for you.

3)      Submit a paper CMS 855I enrollment document to the contractor who revoked the Medicare enrollment requesting a change from “revocation” to “voluntary termination.”  Key terms and yes, MPR can help with thatIt’s important to note, this will require the actual Medicare PTAN originally assigned to the provider in the previous Medicare jurisdiction.  This may be difficult to determine and require the involvement of the provider to contact any and all previous employers (including training programs).

4)      KEY:  If the enrollment record is not changed from revocation to voluntary termination, this action will ALWAYS need to be disclosed by the provider as an adverse legal action with EVEY Medicare enrollment or re-validation completed by the provider in the future.

What’s the take a-way from this lesson?  Whenever you are looking to hire new providers who have been working in other Medicare contractor jurisdictions, get their cooperation to obtain their existing individual Medicare PTANS; and the provider’s PECOS record to be sure there are no current revocations.  In addition, be proactive in insuring that any current Medicare enrollments in other Medicare jurisdictions noted in PECOS are voluntarily terminated.  The provider’s prior employer or training program may be taking care of the voluntary termination but you need to be sure of this in each case.  If you are unable to confirm action taken by the prior employer you need to assure the enrollment is terminated.  This will prevent the receipt of that letter of notification of a one-year bar from re-enrollment.  Not a good way to begin a practice at a new location.

MPR has a mission to perform all the enrollment paperwork necessary to let the provider devote more attention to seeing patients without the hassle of spending hours attending to paperwork.  Let us help you secure the comfort of knowing your enrollment process will be smooth and sustained.

To learn more about revocation read the article by Leslie Witkin at PhysiciansFirst.com.

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